Provider Notice issued 09/30/13

Vaccine Administration- Vaccines in the Vaccines For Children (VFC) Program

Allowable CPT Codes and Charges

The department does not pay for the vaccine product itself, as the product is acquired free-of-charge through the VFC program. In accordance with Chapter HK-200, Handbook for Providers of Healthy Kids Services, Section 207.2 Vaccines For Children Program, the department reimburses providers for the administration of vaccines distributed to VFC enrolled providers through the VFC program.

When submitting a claim for the administration of a VFC-acquired vaccine, providers must bill using the CPT code for the specific vaccine product, rather than the vaccine administration service CPT code. However, the charge amount should be the provider's usual and customary (U & C) charge for the appropriate vaccine administration service CPT code, even if that charge exceeds the regional VFC maximum immunization administration fee.

Under VFC policy, providers may only charge one administration fee per vaccine (syringe), regardless of the number of components in the vaccine. Providers cannot charge for additional components for multi-component vaccines.

Affordable Care Act (ACA) Enhanced Vaccine Administration Payments

Vaccine administration services provided from January 1, 2013 through December 31, 2014, are covered under the ACA Primary Care Provider (PCP) enhanced payment program, which was announced in a March 4, 2013 provider notice, Increased Payment for Primary Care Services. The increased rates are paid as an "add-on" through an adjustment process. The adjustment is paid separately from the payment for the service.

Due to some confusion with regard to the allowable administration charges for vaccines administered under the VFC program, some providers have not historically charged the department their full U & C charge for vaccine administration. This caused some providers to receive less than the full adjustment amount allowable under the ACA PCP program. Those providers who are eligible for ACA PCP adjustments and who did not receive the full adjustment up to the Medicare allowable rate because they did not bill their U & C charge for the vaccine administration code may void the paid service and rebill at their U & C. The void will void both the initial department payment and the ACA PCP adjustment. When rebilled, the claim will pay at the department allowable of $6.40, and the adjustment will be calculated as the difference between the department allowable and the Medicare rate or the U & C, whichever is lesser. Void and rebill instructions are in Chapter 300 of the Provider Handbook for 5010 Companion Guide, Section 4.2 Payer Specific Business Rules and Limitations.

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565 option 3 and then option 1.

Theresa A. Eagleson, Administrator

Division of Medical Programs